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I'm going to talk a little bit about the injury patterns relating the the types of fractures and injuries that we see to the mechanisms and physics that are involved and then move on to the initial lifesaving surgical interventions. And these are the things that may have to be done in uh in non specialist centers. And then we're going to talk a little bit about some of the definitive surgical challenges because this is where particularly um the injuries that we see on the battlefield, so very different to those we see in our civilian practice. And this is when this will be when insider will share their experience from looking after casualties from Afghanistan and Iraq. So obviously, the battlefield mechanisms are traditionally divided into ballistics or bullets, injuries and blast injuries. Um I think when we're talking about pelvic injuries, it's worth subdividing blast into those caused by explosions normally from direct, it's like indirect fire weapons. So mortars, Rockettes and bombs dropped by aircraft. The other type of blast injury that was particularly common in Afghanistan and Iraq was the blast injuries caused by mind, landmines or improvised explosive devices that were buried in the ground. So gunshot wounds affecting the pelvis. They do, they do cause some contamination because of the tissue destruction. Um, but hemorrhage very unpredictable, obviously depends on exactly what uh what structures are injured. But interestingly, they don't typically cause the same problems with instability. The pelvic ring itself normally isn't disrupted, although some component of it may well be. But because you're normally getting bullet damage in one specific part of the pelvis, you often don't need to proceed to a skeletal fixation. You are just allowing the wound to be cleaned and um and and heal up. It's important to acknowledge the bullets don't read textbooks. Although these are general rules, they're not absolute. So indirect, indirect fire weapons. So mortars, Rockettes and bombs, these would normally expect to result in pelvic ring fractures that are a bit more similar to um the injuries that we see from falls and high speed. Uh motorcycle injuries, the exact mechanism would be the impact or the force of the explosion itself or the victim being thrown against the wall or other object. Or we see a lot of these injuries in building collapses after bombings because they're blunt trauma, they are not necessarily heavily contaminated. Um but hemorrhage and instability is often a significant problem. And as we all know, there's uh typically describe the two main types um as anterior, posterior compression. So a front to back force which opens up the pelvic ring um and then the lateral compression where a force exerted from the side closes down one side of the pelvic ring. Um As we come to you later, there's in, um, in the blast injuries from minds, we tend to see a different, different pattern. So blast, blast weapons that are buried in the ground, either landmines or improvised explosives. These can produce quite a different pattern of pelvic pelvic injury. Um It's something that really is unique and different from our civilian civilian experience. So the pelvic injuries are seen in the context of normally one or two traumatic amputations of the lower limbs, significant tissue disruption and often massive hemorrhage, focusing and just on the bony component of the injury for a moment. This is actually unique from the traditional anterior posterior injury. So the force of the blast is directed upwards and so this has an inferior to superior opening up of the pelvic ring. So in a traditional young and Burgess classification, this would be described as a bilateral vertical shear. So going on to the initial um initial surgical treatment, um obviously, the priorities are to save life, uh save limbs and to set things up for the future surgical team to be able to prepare for reconstructive treatment. The first goal is to prevent bleeding and control the hemorrhage and then after that, it, the focus shifts to starting to treat the the often quite significant contamination. There's often a lot of discussion about the source of bleeding for pelvic fractures. Um If you ask a radio radiologist, they will say it's the arteries. Um I think orthopedic surgeons, we tend to feel that a lot of the bleeding comes from the fractures themselves. Obviously, in reality, it's a combination of vessels and, and and the bones in severe hemorrhage, it may be necessary to gain proximal control. In other words, um either surgical clamping of the descending aorta or common iliac six or there's potential for um specialist interventional radiology, guided embolization. Or increasingly the use of a blind, um non specialist balloon occlusion devices, for example, rabona, obviously, it's impossible to get hemorrhage control were from within the zone of injury. Um if someone is bleeding profusely, and so, um as surgeons, we would normally be more comfortable in accessing an artery outside of the zone of injury and including that temporarily. So, um if proximal control has been gained or if it's not necessary, normally, the next stage is to provide some kind of temporary stabilization. Um Traditionally, this was uh emergency external fixators, but increasingly we're using pelvic binders. And when I was a medical student, I was taught that sheets had to be bound around a fractured pelvis as tightly as possible with too strong rugby playing orthopaedics, orthopaedics students. Um but we know now that the force isn't necessary to stabilize, the pelvis are moderate at best. Um and provide placing significant forces through a pelvic binder will just result in pressure sores and tissue damage. Um Similarly, there's been lots of theories as to the mode of Axion for binders over the years. Um I think most of us have settled on the idea that all they do is stabilize fractures to allow clots to form. Um I think the idea of reducing the internal circumference of the pelvis too, tamponade blood loss. Um I'm skeptical of that myself and I think that's been experimentally disproved. So with external fixators um in an emergency setting, we would place these pins open. So without relying on X ray control, necessarily, we would do a direct cut down to the I'll yeah crest and insert them under vision. Now, this traditional method of external fixation um was found to be inadequate for um controlling the very unstable bilateral vertical share. Um uh last landmine type fractures. And so, one of the techniques that developed was to place a mini external fixator in the pubic tube icals as we can see on the image on the bottom left, which allows you to points of fixation and allows you to gain the stability. As you see on the image of the top, on the top left, the, the pelvis can't be closed down just using the traditional iliac crest external fixator pins. Another advantage of this technique is um you don't necessarily need X ray. Um and you can do it by directly cutting down onto the uh anterior um part of the pelvic ring. The pubic rami if you have more time. And um there is X ray guidance available. The super A acetabular or lateral corridor pin sites are an option to give you greater stability, but this is technically a bit more demanding. Um And you do need a good X ray technician to help you um to get the outlook, Judeh views for patient's with significant difficulty in um hemorrhage control. You may require to move on to pelvic packing. Um The reason why I put this after um stabilisation is because you can only pack a pelvis that has been stabilized. In theory, you can do this with the pelvic binder. But I think most of us would find the results would be better once the pelvis is truly stabilized with an external fixator. So if you are not a general surgeon, it is important to discuss this with your general surgical colleague. Um Normally I would prefer a Pfannenstiel incision, but if they are going to do a laparotomy, then this would need to be a midline incision. Um because we are aiming to get into the retroperitoneal space outside of the abdomen proper after significant pelvic trauma. This approach is actually a lot easier because many of the tissue planes have been disrupted and you can quite quickly get down to the sacred I'll yak joints, which is where you have to start packing up from. So you start deep and work your way superficial back to the front of the pelvis, the CT scan on the top right shows a pelvis that have been packed all the way down to the sacroiliac joint and this is a scan that shows a an ineffective pelvic packing. This was a this is a CT scan that demonstrates um pelvic packing that is too superficial to be effective. The packs are all sitting um somewhere just under the fascial layer, probably so finally contamination. Um This is a photograph from um in Mystery and Sergeants Collection. Um and it shows really the the upper end of the complexity um that these injuries can present the surgeon with. Um he hasn't got the smallest of hands. Um and he's able to um to uh completely occupy the synthesis with his left fist in this image. So a surgical priority is a colostomy um in order to prevent ongoing fecal contamination of what is already an open pelvic fracture. The Euro genital trauma is enormous and probably a talk in its own, right? Um But obviously quite a long term priority for reconstruction. So I think I I would be very foolish if I spoke to this area when I have a world expert here. So uh do you want to share some of your thoughts on your, your strategy for dealing with these really challenging injuries? Thank you John for a wonderful talk. You've really set the scene there and I'll talk now perhaps about the the receipt of these patient's that I was familiar with. Uh the first thing I'd like to do is just to reinforce the stages of these sorts of injury and where the focus of treatment should be focused. And stage one is of course, hemorrhage control and the treat that the training of colleagues in the battlefield to apply uh tourniquets um was was it was so helpful in sending people back that would otherwise have died. So, hemorrhage control is number one. And then of course, you go on to managing the soft tissues where we look at debridement and the concept of tissue evolution. And finally, the stage of reconstruction, those three stages don't always sit in a nice step wise fashion and we could sometimes be irritated by bleeding when we received these casualties. And we were also reconstructing soft tissues and structures very early on, although we haven't yet finished debridement, and I'll explain that in a minute. So when we're receiving this sort of injury and indeed all others, it was important to recognize from our point of view in the rear lines that the information that we received very seldom, well, maybe it often did, but very often did not reflect the nature of the injury. So you have to be prepared for the unexpected. What you're going to see in your first trip to theater does not always um respect what you expect to see. So preparing your case, preparing your time, preparing your resources, you can think of a number of bullet points. But the things that spring to my mind are the availability of blood, appropriate time planning, appropriate skill mix and a boss in theater. There needs to be one clinical overseer to make sure that the surgeons go in the right order. And there also needs to be regular updates between the anesthetist and the surgeons or rather the boss to make sure that the patient is still fit for further surgery. Now, this patient and others like him, I remember well, and when they arrived back with us, they had been well resuscitated. Um and they were physiologically surprisingly um stable. But having said that we found by experience that as soon as we touched the limbs. In this case, the gentleman has got to above the amputations. As soon as we started to debride those muscles, we would introduce toxins and dreadful nous into the patient and within about 40 minutes, they would be unfit to continue with the operation to abandon the operation and send them back to I T U for further resuscitation. Yeah. So our concept of prioritization was to put life obviously first and foremost, but we would then be very conscious that preservation of sight, attention to the central nervous system and attention to the hands was hugely important for the patient's future well being and function attending to those injuries did not on the whole make patient's unwell. And we used to, we used to ensure that the hand surgeons, the eye surgeons and any other attending to the CNS would go first and foremost, before we made the patient sick with debridement of the pelvis and the legs. Um having attended to those areas, focus was then put towards the pelvis and the limbs with the general surgeon. And you often a urologist in attendance going on two debridement of the pelvis. Um I think it was, there were several things that we thought were important. The first was to know the anatomy of the area. The second was to know the injury pattern and we found that this open pelvis, as you see a loud blast to pass either side of the rectum, it often dissociated the prostate from the penis. It would go through the sacroiliac joint and it would end up into the paraspinal muscles. The first job was to reach the apex of the wound and ensure that there were no stones, bits of boot place, bits of extraneous uh biology, make sure there was nothing at the apex of the wound. The first trip to theater, we used to get to the apex to make sure that was clean. This job was far easier and far more effective with a friend who knew the anatomy with you bounce ideas often and work with during the operation. Although we were confident that we'd removed foreign material and debris, we were also conscious of the fact that the soft tissues would often misbehave after we had removed this, um the the stones and other debris that was in the patient. So we got the stones and debris out that we were conscious that the soft tissues would often misbehave and the wound would evolve. They're living on. At the same time as we um had cleaned the wound of foreign material, we would then go on to repair soft tissue structures in the pelvis. If there is a discontinuity between the prostate and the base of the penis, we would bring those into continuity and we'd also repair anal and rectal splits. We would do that before we put the external fixator on the pelvis because you can see there that the exposure to those structures through the injury is excellent. And even if the repair of the uh your genital system or the gastrointestinal system failed, we had a d functioning colostomy to protect approximately and a suprapubic catheter to protect the urogenital system and having those structures brought back to close anatomical proximity meant that any future secondary repairs would inevitably be easier. The external fixator technique that Joanne showed you. Um we used to try and reduce the amount of metal work within patient's and reduce the tendency for contamination to become full blown infection, hiding behind metal work two more points. Now, I'll talk about topical negative pressure and timing of return to theater. So topical negative pressure, you may notice back therapy we used um very much during these uh during these times and particularly for this sort of sort of wound. The important thing that I felt and many colleagues felt was that one should not allow um contaminated spaces to become closed spaces that became infected. And the topical negative pressure, we we settled on gauze for these injuries rather than sponge. We would thread the gauze right the way up through that wound into the, through a past the side of the rectum into the paraspinal muscle. We were conscious that that this vaccine in the suction from the surface vacuum would not be transferred all the way up there. So we used to take a tube, cut little holes into it, wrapped the gauls around that and tuck that whole system right up into the apex of the wound, repeated trips to theater. And we used to drawback this device by as much as you thought was appropriate, repeated trips to theater, leave the wounds open and they healed up from the bottom and the patient's were safe that way. Um in terms of return to theater, these cases take a lot of time and effort and we used to use instead of a didactic go back every two days, we would take the patient back at the time when they were at their best. May have been 2 may have been five days. Um And the markers I found those useful were simple orthopedic markers, c reactive protein white cell counts, temperature was not always useful because patient's often had a temperature, but the amount of iron attribute support that patient's were needing was useful as well. So, in my basic principles for these wounds were too ensure that the wounds were treated in a safe fashion by leaving them open, understanding that wounds would evolve and change as time goes on and making sure you get to the top of the wound at the first trip to theater and knowing that the soft tissues will evolve and die even though you're not expecting it and don't close the wound until they stopped dying. Yeah. And as a final, we found that putting a free flap on tissue that's going to die, didn't stop it dying and free flaps fell off. Thank you. So, I've given a lot of anecdote, perhaps not very much science and maybe I could ask Joran to just comment to see if there's anything I've said that was totally at odds with what is true and regular. Thank you very much. That was awesome. Uh Masterclass. Um I think these injuries just lie outside of an area where we can study very readily, don't they? So I think Ian painted a picture of how much time and resources these patient's at the very limits of survival will take up from your hospital system. Um That's a very difficult, a difficult thing that may have to be born into consideration from time to time. So as we're getting near the end of the talk, we're just talk about a couple of treatment strategies for both the little stabilization and the soft tissue reconstruction. Now, so the principles really in these potentially still contaminated wounds should be minimally invasive with minimal amount of metal work or implants. And maybe that you have to accept a non an atomic reduction to reduce the insult of large surgical exposures. Uh An example, this is a very unwell patient still needing iron, a tropes. And so rather than provide an open reduction and internal fixation, we were able to stabilize him using percutaneous techniques. And typically, um this would be uh at the front. Increasingly we use the in fix or the internal external fixator. And this is a larger version of the spinal stabilization devices. So a pedicle screw and a titanium bar that's tunneled in the subcutaneous fat and so is lying completely internally but acts very much like an external fixator. And typically, we'd pear these up with screws, percutaneous cannulated screws in the S one and S two boney channel channels. But you can see as in this case, there is an imperfect reduction. His pelvic ring is not symmetrical, but this is uh an acceptable trade off in the physiologically unstable patient. So for the definitive soft tissue reconstruction, um exactly as is Ian was talking about an incredibly complicated ballet where complex wounds might in one area and be undergoing grafting and free flap cover. And in another area there might be ongoing debridement or excision. Um And you can see the um the patient on the right who have seen the images of earlier, almost 90% away along his journey for definitive treatment. So I think that that's going to bring things to the end. Um uh You know, have you got any other, any other point you'd like to, to wrap up with? I don't think so. Joe and I'm very happy. Thank you. You've done an excellent job there.